Incident investigation·March 20, 2025

Licensing Program Analysts (LPAs) Marcella Tarin and Manuel Monter arrived unannounced to conduct a case management visit to follow up on a medication error. LPAs met with General Manager (GM) Candance Bolin and stated the purpose of the visit. On 3/4/2025 the Department received an Incident Report for a medication error of Resident R1 that occurred on on 2/27/2025. The incident report states: " On Thursday, February 27th. It was reported that the Staff S1 administered two doses of Medication (referred to as M1) to resident R1. The medication order specified 10mg of M1 to be given at 4:00PM and 8:00PM. M1 was supplied in syringes as 10mg/5mL. However, two syringes were administered during each scheduled time, resulting in the resident receiving a total of 20mg at 4PM and another 20mg at 8PM. This is confirmed by the med tech (referred to as staff S1) signatures and sign-out on the record. indicating the admin of 2 syringes at both 4PM and 8PM and the M1 count, showing 2 additional syringes being removed...S1 will undergo retraining on medication administration, focusing on dosages calculation, concentration awareness and the importance of double-checking orders...and an inservice will be provided to all Med techs on Medication errors and their prevention." LPAs interviewed Health Services Director (HSD), who stated Staff S1 admitted to giving two doses of M1 to R1 on 2/27/2025. HSD states S1 did not conduct the required medication checks before administering M1 to R1. A deficiency is being issued during today's visit per California Code of Regulations, Title 22, see LIC809D. An exit interview was conducted with General Manager, Candace Bolin and a copy of this report was provided. Appeal rights were also provided.